Voters supporting Proposition E believing they will be blocking the Affordable Care Act access to the state will likely be disappointed to learn no matter the outcome on Nov. 6, a health insurance exchange of some type will be established, though their votes may influence its efficiency.

Prop E asks voters if state law should be amended “to prohibit the Governor or any state agency, from establishing or operating state-based health insurance exchanges unless authorized by a vote of the people or by the legislature?”

Health insurance exchanges are a key piece of the ACA. Each state is required to have an exchange, which would serve as a private insurance marketplace for consumers and small businesses.

Ryan Barker, director of health policy for the non-partisan Missouri Foundation for Health, said the exchanges aim to bring affordable insurance to those who may be currently priced out. Currently, large employers can offer affordable plans because their high number of employees provide them buying power, something individuals and small businesses don’t have, Barker said.

The health insurance exchanges would pool small businesses and individuals together, in essence becoming a large employer and leveraging those numbers for lower insurance rates.

The ACA requires states to establish exchanges in one of three ways: a state run exchange, an exchange run in partnership by the state and federal government, or a federally run exchange.

The exchanges are scheduled to go online Jan. 1, 2014.

A “yes” vote on Prop E would prohibit the governor from establishing a state exchange by executive order and prevent state officials and agencies from implementing a health insurance exchange without legislative or voter approval.

But as the ACA is federal law, a health insurance exchange would be established in Missouri. If Prop E passes, it would be created and run by the federal government.

“It would not stop us from getting a health insurance exchange because federal law trumps state law,” Barker said. “Every state will have an exchange. If the state doesn’t do it, the feds will come in.”

The Missouri Foundation for Health does endorse legislative issues, as Barker said the organization’s role is to look out for consumers. And he said if Prop E passes, consumers utilizing the exchange in the future may have a more difficult path.

If, for example, an individual were to access the federally-run exchange and was determined to be eligible for Missouri’s Medicaid program, the two computer systems may not be able to communicate with each other due to Prop E’s language.

And because Prop E would permit Missourians to sue state officials, departments, divisions, agencies or political subdivisions that “provide assistance or resources of any kind” to the federal health exchange, Barker said that could impact the “consumer friendliness” of the overall experience by making state employees less likely to provide information.

Page 2 of 2 - Even if Prop E fails, Missouri is likely headed to a federally-operated health insurance exchange for at least 2014. States are to notify the federal government by Nov. 16 on the method each would use to establish an exchange, and Missouri has taken no steps toward preparing its own exchange.

Barker said the ACA provides states an opportunity to change their method each November, which could allow Missouri to change to a state-run exchange in the future.

Barker said he believes a state-run exchange is advantageous for Missouri consumers because the Missouri Department of Insurance, which interacts with private insurance companies and understands state regulations, would likely be involved in the exchange.

“I think we lose something if we let the feds do this,” Barker said. “They are going to have to set these up in a few states. As much as they’d try to tailor it to different needs of different states, a lot of aspects are going to have to be one size fits all.”